Remote Health Appeals & Grievance Case Specialist

RPMGlobal; Philadelphia (Philadelphia County); Hybrid; USD 60,000 - 80,000; Full time

Benefits offered by this job

Flexible work options

Hybrid work schedules

Paid time off including holidays and$0

Health insurance coverage for you and

Job summary

AmeriHealth Caritas in Philadelphia, PA is hiring an Appeals & Grievance Case Resolution Specialist to manage the full life cycle of member and provider appeals and grievances, from intake to resolution, ensuring accuracy and regulatory compliance.

You will collaborate with Claims, Medical Management, Legal and Compliance, document all activities in the case management system, and uphold CMS, NCQA and URAC requirements while delivering timely determinations.

Qualifications

• Associate degree in Health Administration, Business, or related field preferred.
• High School Diploma/GED required.
• Knowledge of medical terminology and regulatory processes preferred.
• 2–3 years in healthcare operations, managed care, or grievances/appeals.
• Proficiency in Microsoft Office.

Responsibilities

• Manage case intake, investigation, and documentation for appeals.
• Collaborate with Claims, Medical Management, Legal, and Compliance.
• Ensure compliance with CMS, NCQA, URAC and HIPAA requirements.
• Maintain case files and timelines.

Skills

Attention to detail

Analytical skills

Customer service

Communication

Education

Associates degree in Health Admin/Business

High School Diploma/GED

Tools

Microsoft Office Suite

Job description

AmeriHealth Caritas in Philadelphia, PA is hiring an Appeals & Grievance Case Resolution Specialist to manage the full life cycle of member and provider appeals and grievances, from intake to resolution, ensuring accuracy and regulatory compliance.

You will collaborate with Claims, Medical Management, Legal and Compliance, document all activities in the case management system, and uphold CMS, NCQA and URAC requirements while delivering timely determinations.